New Quality Measures

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Lexington Medical Center Cancer Services is a Commission on Cancer (CoC) accredited cancer program. CoC review and accreditation involves all aspects of our cancer program, the specifics of which are addressed by our Cancer Committee, participating physicians, providers and support staff, and our Cancer Registry. We have extensive ongoing efforts to meet the clinical quality standards put forth by CoC, as well as to continue to meet and exceed programmatic and organizational standards.

LEXINGTON MEDICAL CENTER 2720 Sunset Boulevard, West Columbia, SC 29169 LexMed.com 3-2014/500/Sun

New Quality Measures


NEW QUALITY MEASURES For the upcoming year, there are 10 new Cancer Program Practice Profiles Report (CP3R) standards to share with LMC physicians and staff. As we see these patients in all multi-disciplinary settings at the hospital, we want to meet these quality standards and will continue to reach out to everyone involved to help with that effort. New breast measures were first implemented with 2013 abstracting/ cancer data collection. The remaining measures are anticipated by January 2014.


BREAST MEASURES Adopted By CoC/QIC Expected Implementation August 2013

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Radiation therapy is considered or administered within one year (365 days) of diagnosis for women undergoing mastectomy for breast cancer with => 4 positive regional lymph nodes. Needle biopsy is performed prior to surgical treatment of breast cancer. Breast conservation rate for women with AJCC Stage 0, I or II breast cancer (surveillance).


GASTRIC MEASURES Adopted By CoC/QIC In May 2013

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Neoadjuvant or adjuvant chemotherapy is administered or considered for Stage IB-IIIC (M0) gastric cancer for patients 18-79 years of age.

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Removal of 15 or more lymph nodes are pathologically examined for resected gastric cancer (excludes Stage IV).


NON-SMALL CELL LUNG CANCER (NSCLC) Adopted By CoC/QIC In May 2013

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Systemic chemotherapy is considered or administered within four months to day preoperatively or day of surgery to six months postoperatively or surgically resected cases with pathologic, lymph node positive (pN1) and (pN2) NSCLC.

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A total of at least 10 lymph nodes are removed and pathologically examined for resected non-small cell lung cancer (pathologic Stage IA, IB, IIA, IIB) surveillance measure.

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Surgery is not the first course of treatment for cN2, M0 cases. Compare NSCLC resection rate to all NCDB – Path T by type of resection surveillance measure.


RECTAL MEASURE (REVISION) Adopted By CoC/QIC In May 2013

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Radiation and chemotherapy administered or considered for AJCC Stage II or Stage III resected rectal cancer patients younger than 80 years of age. A. Surgical resection within 120 days of start of either radiation administration or chemotherapy considered (whichever starts first). B. Chemotherapy considered or administered within 90 days of surgery.


ESOPHAGEAL MEASURE Adopted By CoC/QIC In May 2013

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Neoadjuvant chemotherapy, radiation and surgery within 120 days of first radiation for esophagus and GE junction.


Lexington Medical Center Cancer Services is a Commission on Cancer (CoC) accredited cancer program. CoC review and accreditation involves all aspects of our cancer program, the specifics of which are addressed by our Cancer Committee, participating physicians, providers and support staff, and our Cancer Registry. We have extensive ongoing efforts to meet the clinical quality standards put forth by CoC, as well as to continue to meet and exceed programmatic and organizational standards.

LEXINGTON MEDICAL CENTER 2720 Sunset Boulevard, West Columbia, SC 29169 LexMed.com 3-2014/500/Sun

New Quality Measures


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